1Peart A, et al. BMJ Open 2018;8:e019252. doi:10.1136/bmjopen-2017-019252

Open Access

Patient navigators facilitating access to primary care: a scoping review

Annette Peart,1 Virginia Lewis,2 Ted Brown,3 Grant Russell1

To cite: Peart A, Lewis V, Brown T, et al. Patient navigators facilitating access to primary care: a scoping review. BMJ Open 2018;8:e019252. doi:10.1136/bmjopen-2017-019252

► Prepublication history and additional material for this paper are available online. To view these files, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2017- 019252).

Received 21 August 2017Revised 6 February 2018Accepted 12 February 2018

1Southern Academic Primary Care Research Unit, Department of General Practice, School of Primary and Allied Health Care, Monash University, Notting Hill, Australia2Australian Institute for Primary Care and Ageing, La Trobe University, Melbourne, Australia3Department of Occupational Therapy, Monash University, Frankston, Australia

Correspondence toAnnette Peart; annette. peart@ monash. edu

Research

AbstrACtObjective Patient navigators are a promising mechanism to link patients with primary care. While navigators have been used in population health promotion and prevention programmes, their impact on access to primary care is not clear. The aim of this scoping review was to examine the use of patient navigators to facilitate access to primary care and how they were defined and described, their components and the extent to which they were patient centred.setting and participants We used the Arksey and O’Malley scoping review method. Searches were conducted in MEDLINE, Embase, ProQuest Medical, other key databases and grey literature for studies reported in English from January 2000 to April 2016. We defined a patient navigator as a person or process creating a connection or link between a person needing primary care and a primary care provider. Our target population was people without a regular source of, affiliation or connection with primary care. Studies were included if they reported on participants who were connected to primary care by patient navigation and attended or made an appointment with a primary care provider. Data analysis involved descriptive numerical summaries and content analysis.results Twenty studies were included in the final scoping review. Most studies referred to ‘patient navigator’ or ‘navigation’ as the mechanism of connection to primary care. As such, we grouped the components according to Freeman’s nine-principle framework of patient navigation. Seventeen studies included elements of patient-centred care: informed and involved patient, receptive and responsive health professionals and a coordinated, supportive healthcare environment.Conclusions Patient navigators may assist to connect people requiring primary care to appropriate providers and extend the concept of patient-centred care across different healthcare settings. Navigation requires further study to determine impact and cost-effectiveness and explore the experience of patients and their families.

IntrOduCtIOn Primary care is the first level of access to healthcare, delivered in the community most often by family physicians or general medical practitioners. However, not all people access primary care that best meets their health-care needs, where and when they need it. Some people, such as those living in poverty, with a long-term disability, from a cultur-ally and linguistically diverse background

or located in rural and remote areas, have difficulty accessing primary care services and resources.1–4

Access to healthcare is the opportunity to reach and obtain appropriate healthcare in situations of perceived need.5 Access to primary care is important to reduce health-care disparities, mortality, morbidity, hospital-isation rates and healthcare costs.6–9 Recent reforms to primary care have focused on trialling new processes and models of care to improve access.10 These include integrated care models, after-hours telephone consul-tations, walk-in centres and nurse-led initia-tives. However, disparities in care remain for many, such as people having low literacy and numeracy, cognitive deficits, being a member of a marginalised group or not understanding the need for primary care.11

A new approach to improve access to primary care is patient navigation, a process where a person (navigator) engages with a patient to determine barriers to care and provides information to improve access to components of the health system, not just primary care.12 A patient navigator has been described as a type of ‘broker’ who uses a biopsychosocial approach to provide a range of instrumental and relational functions and processes13 14 to support patients to access primary care and directly identify providers willing to treat vulnerable people requiring

strengths and limitations of this study

► This is the first scoping review to explore how pa-tient navigators are defined, described and used to facilitate access to primary care for people without an affiliation to a primary care provider.

► It is a comprehensive overview of sources covering peer-reviewed and grey literature.

► Sources were included only if the outcome of the navigation was reported; sources describing pa-tient navigation without reporting of outcomes were excluded.

► The inclusion of a description of the patient  cen-tredness of the sources is a unique addition to this review of patient navigators.

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Open Access

care.15 Patient navigator tasks can include educating patients about early symptoms of cancer (in preventive care) or facilitating and coordinating appointments with providers to improve access to a regular primary care provider. Originating in the 1990s, Freeman devel-oped patient navigation as a strategy to reduce barriers to breast cancer care in Harlem, New York.16 Since then, patient navigators have been used for the screening of various cancers and through the cancer care continuum, with mixed success.17–27 In primary care, navigators may have a role in improving access and coordination of care, especially for vulnerable populations whose access to care may be compromised by a range of geographic, demo-graphic, socioeconomic or cultural characteristics.28

Patient-centred care is a core element of high-quality primary care, facilitates access to appropriate care11 and has been identified as one of six areas of focus for improving healthcare systems.29 In primary care, patient-centred care consists of interactions and relation-ships between providers and patients to share information, explore values and preferences, facilitate access to appro-priate care, and address healthcare disparities.30 31 While numerous frameworks of patient-centred care have been described,32 Epstein’s11 succinct model of patient-cen-tred care comprising an informed and involved patient, receptive and responsive health professionals and a coor-dinated, supportive healthcare environment, sits well within the context of patient navigation and its extension beyond the patient–clinician relationship to the setting in which care is delivered.

While navigators have been used in population health promotion and prevention programs,33 34 there has been recent interest in their use in facilitating access to primary care for vulnerable people without a regular primary care provider.28 Understanding the compo-nents of these programmes can assist those interested in designing or implementing similar programmes. There-fore, we performed a scoping review of the use of patient navigation to facilitate access to primary care. Given its importance and relevance to navigation, we included an additional focus on the extent to which identified patient navigation interventions were patient centred.

MethOdsWe chose the scoping review method to map the extent, range and nature of published research on the use of patient navigation to further understand how it links people to primary care.35 When compared with system-atic reviews, scoping reviews address broader topics and are less reliant on detailed research questions or quality assessments.35 The work was structured around the five stages of the Arksey and O’Malley framework: (1) iden-tify the research question, (2) identify relevant studies, (3) study selection, (4) chart the data and (5) collate, summarise and report the results. The review was also informed by Levac et al’s36 refinements to Arksey and O’Malley’s framework.

stage 1: identify the research questionPatient navigation has been defined as a ‘process, by which an individual, a patient navigator, guides patients in overcoming barriers to healthcare services access to facilitate timely access to care’.37 We expanded this defini-tion to include a patient navigator as a person or process creating a connection or link between a person needing primary care and a primary care provider.

Our target population was people without a regular source of or affiliation or connection with primary care. The outcome of interest was the person needing care attended an appointment or made contact with the referred primary care provider. These definitions helped us to clarify the focus of the review, confirm the inclu-sion criteria adopted and establish parameters for the search strategy.36 This review did not focus on the impact or effectiveness of patient navigation programmes in this context. We asked three questions to guide the scoping review:1. How have patient navigators been defined and de-

scribed in connecting people who are unattached to primary care to a primary care provider for regular care?

2. What are the components of these patient navigation programmes?

3. To what extent has patient centredness been incorpo-rated into the design, implementation and analysis of patient navigation programmes?

stage 2: identify relevant studiesWe identified relevant studies through a search of elec-tronic databases, grey literature and reference lists of key articles sourced (online supplementary file 1).

A three-step search strategy was used. First, we under-took an initial limited search of MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Litera-ture (CINAHL) using terms and variants of ‘navigator’, ‘broker’, ‘link worker’ and ‘community health worker’. We analysed the text in the titles and abstracts of retrieved studies and index terms used to refine key terms. The terms most common were related to navigation, linkage and access to care. We completed a second search of the same databases and extended the search to include related medical and social science databases and grey literature using the key terms and variants (table 1) iden-tified by the initial search strategy (online supplementary file 2).

Finally, we checked the reference lists of all identified studies (and their citations) for additional studies.

stage 3: study selectionInclusion criteria were applied as a basis for which studies were considered relevant to the review questions. Studies were included if they:

► were published in English from January 2000 to May 2016. The start date of 2000 reflects the increasing interest in patient-centred care in the last two decades. Reforms of primary care commenced around this

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Open Access

time29 along with the emergence of navigator-type approaches38;

► reported on patients who did not have a regular source of primary care (provider or practice);

► connected patients to primary care by a process (eg, navigation) or a person (eg, navigator);

► reported an outcome of patients attending or making at least one appointment with primary care providers.

We excluded studies if they originated in countries who were not members of the Organisation for Economic Cooperation and Development (OECD), as their primary care systems differ significantly from those of OECD countries. Other exclusion criteria were applied to studies where:

► patients lived in residential care, or incarcerated with no imminent release date, as their primary care needs were assumed to be met by institutional providers;

► a navigator was attached to a primary care provider or practice as this indicated the patient was already connected to primary care;

► a navigator referred patients to health screening or assessment services only and not to a primary care provider.

AP reviewed titles and abstracts of studies, and GR inde-pendently reviewed abstracts where there was uncertainty for inclusion.

stage 4: chart the dataData extracted were entered into a template developed in Microsoft Excel specifically for this review. Information on authors, year of publication, study location and context, aims or purpose of the research, study type or design, population and sample size, methodology, conceptual model, intervention type and duration, measures used and key findings were recorded on this form. We also extracted data relevant to the research questions: defi-nitions and descriptions of navigators, components of navigator programmes and elements of patient-centred care. Charting the data was an iterative process36 that we updated as studies revealed useful data categories. Studies were reviewed a number of times to ensure all relevant data was captured.

stage 5: collate, summarise and report the resultsWe collated the data using a Microsoft Excel spreadsheet. Excerpts of text were coded deductively by AP to identify concepts and themes related to the research questions. GR checked the coding scheme and the themes raised.

resultsOur initial search terms generated 6355 records from electronic databases and grey literature (figure 1). We removed 664 duplicates, leaving 5691 records to be screened. Of these, 5613 records were excluded based on the title and/or abstract review, as they were not rele-vant to the question, did not meet inclusion criteria or originated in non-OECD countries. Of the remaining 78 records, full-text review excluded 44 where participants were not linked to primary care and 16 where participants already had a primary care provider or did not indicate a need for primary care. We searched references and cita-tions of the remaining 18 records, adding two additional studies. This resulted in 20 selected for inclusion in the scoping review. The selection process is shown in the flow chart (figure 1).

Of the 20 included studies, three reported on the same randomised controlled trial at different phases.39–41 These three studies were counted as unique studies as each reported on different elements of the same trial: preliminary findings, qualitative analysis of interviews and longitudinal findings.

Eleven studies were descriptions or evaluations of programmes, eight were intervention studies and one was a retrospective study. Thirteen were programmes based in emergency departments, six were community-based programmes and one was delivered in an inpatient setting. All studies were conducted in the USA. Table 2 outlines characteristics of the included studies.

Patient navigators: definition and descriptionsOne study defined patient navigation as a ‘process, by which an individual, a Patient Navigator, guides patients in overcoming barriers to health care services access to facilitate timely access to care’.37 The studies provided either a description of a navigator (person) or, for three of the studies, navigation process.42–44 Descriptions varied in detail and often consisted of the type of person recruited as a navigator, the tasks they performed and the training provided (table 2).

Patient navigation programme componentsAll of the studies outlined components of their programmes; four provided detailed descrip-tions.39–41 45 We grouped programme components according to Freeman’s consensus-based nine-principle framework of patient navigation, originally developed in response to the expansion of patient navigation as a community-based intervention.16 46 47 These principles have been widely used in patient navigation programmes. Each of these principles is outlined below with examples

Table 1 Key search terms

Concept, programmeor intervention Setting

Navigator/navigationPatient navigator/navigationPeer navigator/navigationBrokerHealth brokerHealth services brokerCommunity health workerCommunity navigator/navigationLay health workerLinkage to care

Community healthFamily practice/practitionerGeneral practice/practitionerPrimary carePrimary healthcare

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Open Access

from the studies selected that included sufficient infor-mation to inform each principle in the framework.

Principle 1: patient-centred healthcare service delivery modelSeventeen of the studies outlined aspects of patient-cen-tred care. This will be discussed further in the section addressing research question three.

Principle 2: integration of a fragmented healthcare systemThis principle relates to a patient experiencing a seam-less, timely flow through the continuum of care.16 We grouped another principle (principle 8: connect discon-nected healthcare systems) here with principle 2, as the two are similar concepts, and this has been done previously.48 All studies in our scoping review reported on these prin-ciples grouped together. Two examples of integration in our scoping review were assisting patients to understand the entire health system,49 and linking the emergency department with a primary care provider, as well as to community dental, mental health, substance abuse and other social services.50

Principle 3: elimination of barriersThis principle is most effectively carried out through relationships with patients.16 While removing barriers to accessing primary care appears implicit in a navigator

programme, not all studies provided detail of what the barriers were and how they were addressed. One exception of note is the Step on It! intervention at JFK International Airport, which focused on the barriers taxi drivers faced. This intervention went to the airport holding lot, assisted drivers to locate providers with flexible hours, cultur-ally and linguistically appropriate models of care and at low-cost.51 Another study described a programme that helped adults with sickle cell disease find primary care.52 The barriers addressed included patients not under-standing why they needed a primary care provider when they already had a specialist, low literacy, difficulty filling out forms and forgetting appointments. These navigators used motivational interviewing to identify further barriers and help patients set priorities beyond accessing primary care.52

Principle 4: clear scope of practiceThree studies provided detail about the role and respon-sibilities of the navigator.37 45 52 The most detailed of these was a randomised clinical trial by Kangovi et al,45 providing a website link (http:// chw. upenn. edu) containing proto-cols for recruitment, training and standardised work practices for navigators, organisational directors and managers.

Figure 1 Flow of study selection. OECD, Organisation for Economic Cooperation and Development.

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Open Access

Tab

le 2

C

hara

cter

istic

s of

incl

uded

stu

die

s

Aut

hors

Co

ntex

tS

tud

y ty

pe

Po

pul

atio

n an

d

sam

plin

gP

rim

ary

out

com

eD

escr

ipti

on

Bis

hop

49P

rivat

e, n

on-p

rofit

, co

mm

unity

hom

eles

s sh

elte

r

Des

crip

tion

of

Cha

rlott

esvi

lle H

ealth

A

cces

s in

itiat

ive

to

enha

nce

acce

ss t

o ca

re

Hom

eles

s an

d n

ear-

hom

eles

s p

eop

le, w

ithou

t a

heal

thca

re p

rovi

der

, at

tend

ing

heal

th fa

ir at

sh

elte

r or

sou

p k

itche

n (n

o sa

mp

le r

epor

ted

)

Peo

ple

con

nect

ed t

o p

erm

anen

t he

alth

care

p

rovi

der

Volu

ntee

r na

viga

tor

(stu

den

t or

co

mm

unity

mem

ber

) com

ple

ted

a

trai

ning

cou

rse,

eng

aged

per

son

by

bui

ldin

g re

latio

nshi

ps,

ass

esse

d

need

s, g

uid

ed t

o p

rovi

der

s, t

rans

late

d

conf

usin

g in

form

atio

n, c

oord

inat

ed

follo

w-u

p a

nd e

mp

ower

ed p

eop

le t

o un

der

stan

d h

ealth

sys

tem

and

sel

f-ca

re.

Cha

n et

 al42

ED

in lo

w-i

ncom

e,

urb

an a

rea

serv

ed

by

thre

e co

mm

unity

cl

inic

s

Non

-ran

dom

ised

, non

-b

lind

ed in

terv

entio

nal t

rial

to im

pro

ve p

rimar

y ca

re

acce

ss fo

r un

der

serv

ed

pat

ient

s

Pat

ient

s w

ith n

o p

rimar

y ca

re p

rovi

der

ass

esse

d

by

ED

 phy

sici

an t

o b

enefi

t fr

om c

linic

follo

w-u

p

(n=

326)

Pat

ient

s fo

llow

-up

at

com

mun

ity c

linic

with

in

14 d

ays

Inte

rnet

-bas

ed s

ecur

e re

ferr

al s

yste

m

bet

wee

n E

D m

edic

al r

ecor

d a

nd

clin

ic a

pp

oint

men

t sy

stem

s. S

yste

m

acce

ssed

clin

ic a

vaila

bili

ty a

nd a

llow

ed

ED

 phy

sici

ans

to g

ive

pat

ient

s fo

llow

-up

ap

poi

ntm

ents

at

clin

ics.

Dor

an e

t al

57U

rban

, pub

lic, s

afet

y-ne

t ho

spita

l ED

with

p

rimar

y ca

re c

linic

in

sam

e b

uild

ing

com

ple

x

Qua

siex

per

imen

tal t

rial t

o na

viga

te w

illin

g p

atie

nts

from

ED

to

clin

ic

Ad

ults

with

no

prim

ary

care

pro

vid

er, p

rese

ntin

g w

ith lo

w-a

cuity

pro

ble

ms,

as

sign

ed t

o in

terv

entio

n or

usu

al c

are

bas

ed o

n w

here

car

e ex

pec

ted

to

res

ult

in le

ast

del

ay

(n=

965)

Pat

ient

s fo

llow

-up

at

prim

ary

care

clin

ic

with

in 1

yea

r

Trai

ned

pat

ient

nav

igat

or e

scor

ted

p

atie

nts

from

ED

 wai

ting

room

to

clin

ic. P

atie

nts

assi

gned

phy

sici

an

who

ad

dre

ssed

cur

rent

pro

ble

ms,

es

tab

lishe

d c

are

pla

n an

d g

ave

card

w

ith n

ame

and

clin

ic t

elep

hone

num

ber

.

Elli

ott 

et a

l43U

rban

ED

, ser

ving

hi

gh p

rop

ortio

n of

vu

lner

able

pat

ient

s

Ret

rosp

ectiv

e st

udy

usin

g fu

ll el

ectr

onic

med

ical

re

cord

ab

stra

ctio

n,

rand

omly

sam

ple

d

Pat

ient

s w

ith n

o p

rimar

y ca

re p

rovi

der

, d

isch

arge

d a

nd r

efer

red

to

tra

nsiti

onal

car

e cl

inic

(n

=66

0)

Pat

ient

com

ple

ted

fo

llow

-up

vis

it in

tr

ansi

tiona

l car

e cl

inic

as

sch

edul

ed

Tran

sitio

nal c

are

clin

ic s

taff

wor

ked

with

p

atie

nts

to d

eter

min

e p

refe

renc

es a

nd

loca

te c

onve

nien

t, a

pp

rop

riate

pro

vid

er

and

mad

e ne

w a

pp

oint

men

t w

ith

chos

en p

rovi

der

.

Gan

y et

 al51

Unu

sed

par

king

lo

t ad

jace

nt t

o JF

K

Inte

rnat

iona

l Airp

ort’s

ta

xi h

old

ing

lot

Des

crip

tion

of S

tep

On

It! w

orkp

lace

inte

rven

tion

to in

crea

se h

ealth

care

ac

cess

Con

veni

ence

sam

ple

of

taxi

driv

ers

wai

ting

in

airp

ort

hold

ing

lot

(n=

466)

Driv

er c

omp

lete

d

follo

w-u

p v

isit

with

lin

ked

pro

vid

er w

ithin

6

mon

ths

Hea

lthca

re a

cces

s an

d c

ase

man

agem

ent

to li

nk d

river

s to

pro

vid

ers,

in

clud

ing

refe

rral

s to

low

-cos

t (o

r fr

ee) c

ultu

rally

 ap

pro

pria

te c

linic

s or

ho

spita

ls.

Con

tinue

d

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Aut

hors

Co

ntex

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pe

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pul

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plin

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out

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escr

ipti

on

Gris

wol

d e

t al

39–4

1U

rban

Com

pre

hens

ive

Psy

chia

tric

Em

erge

ncy

Pro

gram

(psy

chia

tric

as

sess

men

t an

d

man

agem

ent,

ta

rget

ed t

hera

peu

tic

app

roac

hes,

link

s to

co

mm

unity

men

tal

heal

th s

ervi

ces)

as

usua

l car

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Ran

dom

ised

con

trol

led

tr

ial c

omp

arin

g lin

kage

w

ith p

rimar

y ca

re

with

usu

al c

are

afte

r p

sych

iatr

ic e

mer

genc

y vi

sit

Ad

ults

pre

sent

ing

with

p

sych

iatr

ic d

isor

der

, with

no

prim

ary

care

pro

vid

er

or h

ave

not

seen

one

w

ithin

6 m

onth

s (n

=10

1–17

5)

Pat

ient

s co

nnec

ted

to

and

vis

ited

prim

ary

care

with

in 3

and

12

mon

ths

Car

e na

viga

tor

trai

ned

in in

terv

iew

ing

and

cas

e m

anag

emen

t p

rovi

ded

in

form

atio

n ab

out

low

-cos

t ca

re,

faci

litat

ed a

cces

s an

d r

einf

orce

d p

atie

nt

educ

atio

n; in

form

atio

n to

pro

vid

ers

abou

t p

atie

nt’s

his

tory

, fol

low

-up

, pee

r co

nnec

tions

to

acce

ss c

omm

unity

and

so

cial

ser

vice

s.

Hor

witz

 et 

al58

Leve

l 1 u

rban

tra

uma

cent

reR

and

omis

ed s

tud

y of

inte

nsiv

e ca

se

man

agem

ent

inte

rven

tion

to im

pro

ve p

rimar

y ca

re

use

Uni

nsur

ed a

dul

ts

pre

sent

ing

to E

D,

excl

udin

g su

bst

ance

ab

use

or m

enta

l hea

lth

issu

es o

nly

(n=

230)

Pat

ient

s vi

site

d o

ne

of fo

ur p

artic

ipat

ing

prim

ary

care

clin

ics

with

in 2

mon

ths

Hea

lth P

rom

otio

n A

dvo

cate

s in

ED

as

sist

ed p

atie

nts

to c

hoos

e p

rovi

der

, ga

ve b

roch

ure,

faxe

d in

form

atio

n to

ca

se w

orke

r at

sel

ecte

d c

linic

. Clin

ic

case

wor

ker

cont

acte

d p

atie

nt t

o m

ake

app

oint

men

t.

Kah

n et

 al61

Med

icai

d m

anag

ed

care

org

anis

atio

n fo

r p

eop

le w

ith

men

tal h

ealth

and

/or

sub

stan

ce a

bus

e d

iagn

oses

Eva

luat

ion

to a

sses

s ef

fect

iven

ess

of c

ase

man

agem

ent

in li

nkin

g ne

w m

emb

ers

with

p

rimar

y ca

re p

rovi

der

s

New

mem

ber

s w

ith

beh

avio

ural

hea

lth

dia

gnos

is a

nd n

o p

rimar

y ca

re p

rovi

der

com

ple

ting

mai

led

sur

vey,

ref

erre

d

to c

ase

man

agem

ent

(n=

368)

Mem

ber

vis

ited

prim

ary

care

pro

vid

er w

ithin

12

mon

ths

Tele

pho

ne c

ase

man

ager

s m

ade

at

leas

t th

ree

cont

act

atte

mp

ts t

o en

sure

lin

kage

to

pro

vid

er.

Kan

govi

 et 

al45

Two

urb

an,

acad

emic

ally

 affi

liate

d

hosp

itals

Two-

arm

ed, s

ingl

e-b

lind

, ra

ndom

ised

clin

ical

tria

l to

imp

rove

prim

ary

care

fo

llow

-up

pos

tdis

char

ge

New

ly a

dm

itted

low

-in

com

e, u

nins

ured

or

Med

icai

d a

dul

t in

pat

ient

s ra

ndom

ly n

umb

ered

, ap

pro

ache

d u

ntil

thre

e p

er d

ay e

nrol

led

(n=

446)

Pat

ient

com

ple

ted

fo

llow

-up

vis

it w

ith

prim

ary

care

pro

vid

er

with

in 1

4 d

ays

Com

mun

ity h

ealth

wor

kers

(tra

ined

la

y p

eop

le o

f sim

ilar

bac

kgro

und

s to

p

atie

nts,

sel

ecte

d fo

r p

erso

nalit

y tr

aits

p

atie

nts

iden

tified

as

imp

orta

nt) s

et

goal

s, s

upp

orte

d g

oal a

chie

vem

ent,

co

nnec

ted

to

pro

vid

er.

Kim

 et 

al53

Five

hos

pita

l ED

s in

an

afflu

ent

area

with

larg

e an

d p

oor

imm

igra

nt

pop

ulat

ion

Ana

lysi

s of

Em

erge

ncy

Dep

artm

ent-

Prim

ary

Car

e C

onne

ct in

itiat

ive

to

link

pat

ient

s to

four

loca

l p

rimar

y ca

re c

linic

s

Mer

ged

dat

a se

t (h

osp

ital

dis

char

ge, c

linic

 and

na

viga

tor

refe

rral

dat

a) o

f lo

w-i

ncom

e or

uni

nsur

ed

pat

ient

s w

ith n

o p

rimar

y ca

re p

rovi

der

(n=

10 7

61)

Pat

ient

s co

mp

lete

d

two

or m

ore

visi

ts t

o sa

me

clin

ic a

cros

s 33

-mon

th p

erio

d

Pat

ient

nav

igat

ors

of v

ario

us

bac

kgro

und

s (m

ost

unlic

ence

d,

sele

cted

for

com

mun

icat

ion

skill

s)

bas

ed in

clin

ics

(thre

e si

tes)

or

hosp

itals

(tw

o si

tes)

sp

oke

face

to

face

or

tel

epho

ned

pat

ient

s re

ferr

ed b

y E

D p

rovi

der

s.

Tab

le 2

C

ontin

ued

Con

tinue

d

on April 11, 2020 by guest. P

rotected by copyright.http://bm

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/B

MJ O

pen: first published as 10.1136/bmjopen-2017-019252 on 17 M

arch 2018. Dow

nloaded from

7Peart A, et al. BMJ Open 2018;8:e019252. doi:10.1136/bmjopen-2017-019252

Open Access

Aut

hors

Co

ntex

tS

tud

y ty

pe

Po

pul

atio

n an

d

sam

plin

gP

rim

ary

out

com

eD

escr

ipti

on

Mar

r et

 al50

Urb

an E

D w

ith

high

rat

es o

f p

oten

tially

avo

idab

le

hosp

italis

atio

ns a

nd

lack

of c

omm

unity

-b

ased

car

e

Eva

luat

ion

of p

rogr

amm

e to

con

nect

pat

ient

s w

ith c

omm

unity

-bas

ed,

prim

ary

care

pro

vid

ers

Pat

ient

s w

ith n

o p

rimar

y ca

re p

rovi

der

ap

pro

ache

d

by

navi

gato

r (n

=71

85)

Pat

ient

s co

mp

lete

d

thre

e or

mor

e vi

sits

to

sam

e cl

inic

acr

oss

18-m

onth

per

iod

Pat

ient

nav

igat

or (a

dvo

cate

) rec

ruite

d

from

com

mun

ity, t

rain

ed in

ED

, vis

ited

p

atie

nts

wai

ting

for

med

ical

car

e or

b

efor

e d

isch

arge

, offe

red

ref

erra

l with

in

18-c

linic

sys

tem

.

Ove

rhol

ser 

et a

l52S

pec

ialis

t ou

tpat

ient

cl

inic

s of

urb

an t

ertia

ry

teac

hing

hos

pita

l

Des

crip

tion

of p

atie

nt

navi

gatio

n p

rogr

amm

e to

ove

rcom

e b

arrie

rs t

o fin

din

g p

rimar

y ca

re

Ad

ults

with

sic

kle

cell

dis

ease

with

no

prim

ary

care

pro

vid

er o

r no

t se

en

regu

larly

by

pro

vid

er,

refe

rred

by

spec

ialis

t p

hysi

cian

s (n

=21

)

Pat

ient

s at

tend

ed in

itial

vi

sit

with

new

prim

ary

care

pro

vid

er

Pat

ient

nav

igat

ors

of v

ario

us

bac

kgro

und

s tr

aine

d in

nav

igat

ion

pro

activ

ely

soug

ht lo

cal p

rovi

der

s an

d

esta

blis

hed

net

wor

k th

roug

h ou

trea

ch,

mad

e ap

poi

ntm

ents

with

pat

ient

s, s

ent

rem

ind

ers 

and

ed

ucat

ed o

n im

por

tanc

e of

prim

ary

care

.

Trea

dw

ell e

t al

54A

fric

an-A

mer

ican

co

mm

unity

cen

tre

Eva

luat

ion

of S

ave

Our

Son

s gr

oup

he

alth

ed

ucat

ion

and

in

terv

entio

n m

odel

to

red

uce

inci

den

ce o

f d

iab

etes

and

ob

esity

, im

pro

ve r

egul

ar a

cces

s to

ca

re a

nd b

uild

com

mun

ity

netw

orks

Afr

ican

-Am

eric

an m

en a

t ris

k fo

r or

dia

gnos

ed w

ith

dia

bet

es a

nd/o

r in

poo

r he

alth

rel

ated

to

obes

ity

and

/or

othe

r he

alth

co

ncer

ns; r

ecru

ited

at

com

mun

ity e

vent

(n=

42)

Par

ticip

ants

con

nect

ed

to m

edic

al h

ome

Six

-wee

k co

mm

unity

-bas

ed,

cultu

rally

 res

pon

sive

, gen

der

-sp

ecifi

c he

alth

pre

vent

ion

pro

gram

me

del

iver

ed

by

com

mun

ity h

ealth

wor

kers

, and

tr

uste

d c

omm

unity

mem

ber

s p

rovi

ded

lin

ks b

etw

een

heal

th s

yste

m a

nd

com

mun

ity.

Wan

g et

 al37

Com

mun

ity h

ealth

ce

ntre

pro

vid

ing

com

pre

hens

ive

serv

ices

to

ethn

ical

ly

div

erse

pop

ulat

ion

with

low

inco

mes

or

unin

sure

d

Eva

luat

ion

of p

atie

nt

navi

gatio

n p

rogr

amm

e to

op

timis

e he

alth

care

ut

ilisa

tion

Pat

ient

s w

ith d

iab

etes

an

d/o

r hy

per

tens

ion

not

seen

by

pro

vid

er in

last

6

mon

ths

(n=

215)

Pat

ient

vis

ited

prim

ary

care

pro

vid

er a

nd/o

r ch

roni

c d

isea

se n

urse

w

ithin

6 m

onth

s

Pat

ient

nav

igat

or t

rain

ed in

chr

onic

ill

ness

ed

ucat

ion,

mot

ivat

iona

l in

terv

iew

ing 

and

ap

poi

ntm

ent

sche

dul

ing.

Tel

epho

ned

pat

ient

s, b

uilt

rap

por

t, e

duc

ated

pat

ient

s, m

ade

app

oint

men

t w

ith p

rovi

der

, ass

esse

d

need

for

spec

ialis

t re

ferr

als,

iden

tified

b

arrie

rs t

o ac

cess

 and

ass

iste

d t

o ov

erco

me

bar

riers

.

Wex

ler 

et a

l44E

D w

ithin

urb

an

acad

emic

med

ical

ce

ntre

and

affi

liate

d

prim

ary

care

pra

ctic

es

Ran

dom

ised

con

trol

led

tr

ial c

omp

arin

g he

alth

in

form

atio

n te

chno

logy

in

terv

entio

n to

imp

rove

ac

cess

to

prim

ary

care

, w

ith u

sual

car

e

Med

icai

d e

nrol

lees

who

d

id n

ot h

ave

usua

l sou

rce

of c

are,

ED

 phy

sici

an

confi

rmed

vis

it no

n-ur

gent

, com

ple

ted

b

asel

ine

surv

ey, r

and

omly

as

sign

ed (n

=14

8)

Pat

ient

s at

tend

prim

ary

care

pro

vid

er o

ffice

af

ter

dis

char

ge a

t 3,

6

and

12

mon

ths

ED

ele

ctro

nic

med

ical

rec

ord

to

mak

e ap

poi

ntm

ent

at c

linic

bas

ed o

n p

atie

nt

loca

tion

and

pre

fere

nce.

Pat

ient

gi

ven

app

oint

men

t re

min

der

car

d a

nd

dire

ctio

ns t

o cl

inic

. Ele

ctro

nic

mes

sage

to

clin

ic w

ith in

form

atio

n ab

out

pat

ient

an

d a

pp

oint

men

t.

Tab

le 2

C

ontin

ued

Con

tinue

d

on April 11, 2020 by guest. P

rotected by copyright.http://bm

jopen.bmj.com

/B

MJ O

pen: first published as 10.1136/bmjopen-2017-019252 on 17 M

arch 2018. Dow

nloaded from

8 Peart A, et al. BMJ Open 2018;8:e019252. doi:10.1136/bmjopen-2017-019252

Open Access

Aut

hors

Co

ntex

tS

tud

y ty

pe

Po

pul

atio

n an

d

sam

plin

gP

rim

ary

out

com

eD

escr

ipti

on

Em

erge

ncy 

dep

artm

ent

navi

gato

rs c

onne

ct

pat

ient

s to

bet

ter

venu

es

of c

are55

ED

s of

eig

ht-h

osp

ital

syst

emN

ews

artic

le o

n us

e of

E

D n

avig

ator

s to

red

irect

p

atie

nts

with

non

-em

erge

ncy

issu

es t

o m

ost

app

rop

riate

car

e se

ttin

g

Hea

lth p

lan

mem

ber

s w

ith n

on-u

rgen

t p

rob

lem

s (n

o sa

mp

le r

epor

ted

)

Pat

ient

sch

edul

ed t

o b

e se

en b

y an

othe

r p

rovi

der

Nav

igat

or w

ith c

usto

mer

ser

vice

b

ackg

roun

d a

ssig

ned

mem

ber

s to

p

rovi

der

and

mad

e ap

poi

ntm

ents

.

Nav

igat

or r

educ

es

read

mis

sion

s,

inap

pro

pria

te E

D v

isits

56

Urb

an E

DN

ews

artic

le o

n co

mm

unity

hea

lth

outr

each

wor

ker

help

ing

pat

ient

s fin

d a

prim

ary

care

pro

vid

er

Pat

ient

s w

ith n

on-u

rgen

t p

rob

lem

s w

ho a

re

unin

sure

d a

nd d

o no

t ha

ve a

prim

ary

care

p

rovi

der

, ins

ured

but

d

o no

t ha

ve a

pro

vid

er

or h

ave

a p

rovi

der

but

ca

nnot

acc

ess

him

or

her

(n=

1500

)

Sel

f-p

ay p

atie

nts

find

med

ical

hom

e;

othe

r p

atie

nts

iden

tify

prim

ary

care

pro

vid

er

and

set

up

follo

w-u

p

app

oint

men

t

Com

mun

ity h

ealth

out

reac

h co

ord

inat

or/n

avig

ator

of v

aryi

ng

cultu

res

rep

rese

ntin

g p

atie

nts

serv

ed.

Met

pat

ient

in E

D, c

oord

inat

ed

app

oint

men

ts a

nd s

et p

atie

nts

up in

m

edic

al h

omes

.

ED

nav

igat

ors

help

p

atie

nts

find

a P

CP

59U

rban

ED

New

s ar

ticle

on

a p

ilot

pro

ject

to

red

uce

30-d

ay

read

mis

sion

s an

d n

umb

er

of s

elf-

pay

pat

ient

s w

ho

visi

t E

D fo

r no

n-em

erge

nt

care

Pat

ient

s w

ithou

t in

sura

nce

and

prim

ary

care

pro

vid

er a

dm

itted

to

hos

pita

l thr

ough

ED

an

d/o

r no

t ad

mitt

ed (n

o sa

mp

le r

epor

ted

)

Pat

ient

s d

irect

ed t

o p

rimar

y ca

re p

rovi

der

an

d s

et u

p in

med

ical

ho

me

Nav

igat

or w

orke

d w

ith p

atie

nts

to

dis

cuss

dis

char

ge a

nd h

elp

faci

litat

e fo

llow

-up

ap

poi

ntm

ents

.

ED

, em

erge

ncy

dep

artm

ent;

PC

P, p

rimar

y ca

re p

rovi

der

.

Tab

le 2

C

ontin

ued

on April 11, 2020 by guest. P

rotected by copyright.http://bm

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/B

MJ O

pen: first published as 10.1136/bmjopen-2017-019252 on 17 M

arch 2018. Dow

nloaded from

9Peart A, et al. BMJ Open 2018;8:e019252. doi:10.1136/bmjopen-2017-019252

Open Access

Kangovi et al45 created a community health worker model and tested its effect on posthospital outcomes among general medical inpatients. This was based on qualitative participatory action research and had detailed protocols including standardised work practices in three stages: goal setting, goal support and connection with primary care. A substantial component was to build rela-tionships with patients to help set goals for recovery, develop an individualised action plan and liaise between the patient and inpatient care team. The worker provided tailored support based on the patient goals. Patients were connected to primary care and coached to make and attend appointments independently. Provider resources included a discharge summary and the patient’s action plan taken to the appointment.

Principle 5: cost-effectiveNone of the studies evaluated the cost-effectiveness of their programme.

Principle 6: defined level of skillNine studies provided information on the skill level required of the navigators.39 45 49 50 52–55 This ranged from volunteers with inhouse training, staff with customer service backgrounds, to college-accred-ited navigators. They were trained on topics such as navigation processes, disease-specific content such as diabetes education or motivational interviewing. Similarly, seven studies presented strategies intention-ally used to inform the development of resources to support the navigation intervention, including a needs assessment,49 56 software development,42 commu-nity-based participatory action research45 51 54 and provider collaboration to develop and test navigation mechanisms.50

Principle 7: defined beginning and endEleven studies outlined definite points at which navi-gation began and ended.37 42–45 50 51 56–59 Entry usually involved meeting a patient (eg, in the emergency depart-ment or on a hospital ward) to schedule an appointment. End points of the interventions included ‘patient has an appointment made’ or ‘patient sees provider’.

Principle 8: connect disconnected healthcare systemsThis principle was combined with a similar principle (principle 2: integration of a fragmented healthcare system) for the purposes of this review.

Principle 9: coordinated systemThis principle relates to having an assigned coordinator to oversee all aspects of the intervention.16 This was evident in two studies: where navigators served as executive offi-cers on a governing board49 and were supervised by a social worker as well as having weekly team meetings.45

Patient navigation: patient centrednessOur third question for this review was, ‘To what extent has patient-centredness been incorporated into the

design, implementation and analysis of patient naviga-tion programs?’ We focused on the three factors on which patient-centred care depends: informed and involved patient, receptive and responsive health professionals and a coordinated, supportive healthcare environment.11 Seventeen studies included at least one of the three factors. Table 3 indicates the number of studies and some examples of approaches to patient-centred care for each of the three factors. The columns of the table indicate whether patient centredness was included in the design, implementation or analysis phase of patient navigation programmes.

The Kangovi et al45 study had an explicit patient-centred focus. The intervention prioritised relationship building with patients through goal setting and development of action plans, liaising with inpatient staff to ensure the patient’s goals were at the forefront and giving the action plan to a provider the patient chose based on needs and preferences.

Similarly, in the three studies reporting the same randomised controlled trial, Griswold et al39–41 used a care navigator to connect patients with a history of psychiatric crisis to primary care. The navigator built relationships by meeting with patients routinely while admitted and also at primary care appointments and maintaining regular contact via phone or in person. The navigator would take the patient to the appointment and reinforce any education provided. Patients were informed of low-cost clinics, and further assistance was provided through coor-dinating follow-up and connecting patients to peer and social services. Provider resources included information to clinics on discharge diagnosis, medications and mental health treatment site referral.

Other studies included the three factors yet did not explicitly state patient centredness as a driver.

dIsCussIOnOur scoping review identified 20 studies that used patient navigation to facilitate access, and connect vulnerable patients without regular primary care, to a primary care provider. All except three studies used a person to connect the patient to a provider; the remaining three used a navi-gation process. Most programmes described components that could be included in a framework of patient naviga-tion, and 17 of the 20 studies included factors inherent to patient-centred care in their design, implementation or analysis.

The level of detail in descriptions of the studies varied; this variation has been reported elsewhere.60 In the studies included in this review, different terms were used for the same role: patient or care navigator, advocate, case manager or community health worker, for example. This presents challenges in clearly characterising navigators and understanding what they do. Similarly, while there is no generally accepted definition of patient navigation, there is a call for descriptions of the tasks navigators do and the networks of contacts they use to support their

on April 11, 2020 by guest. P

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pen: first published as 10.1136/bmjopen-2017-019252 on 17 M

arch 2018. Dow

nloaded from

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Open Access

actions.60 Valaitis et al28 described the specific activities undertaken by patient navigators: facilitating access to health-related programmes, promoting and facilitating continuity of care, identifying and removing barriers to care and effective and efficient use of the health system. Our findings add to these activities: a key feature of patient navigation to facilitate access to primary care is a relationship-based approach, informing and involving patients in connecting them to care.

The studies in this scoping review included elements that seemed to match the components of Freeman’s patient navigation framework. This indicates the frame-work may be generalisable to the tasks of connecting vulnerable people without a primary care provider to regular care. An evaluation of these principles used in 10 self-identified breast cancer navigation programmes using observation of patient navigator activities found the programmes were consistent with individual-level princi-ples (eg, eliminating barriers, patient-centred care and integration of care); however, programme-level princi-ples (eg, skill level, scope of practice and coordinated system) were not consistent across the programmes. We did not examine this level of detail for our scoping review, however, can see a role for this type of observa-tion-based study to further contribute to this field.48 Generally, programmes adhered to published criteria for patient-centred care.11 Although not overtly stated as an aim, almost all studies incorporated at least one of the three patient-centred care factors: an informed and

involved patient, receptive and responsive health profes-sionals and a coordinated, supportive healthcare environ-ment. We found these mostly in the implementation of the programmes to a lesser degree in the design phase and mentioned in only three studies in the analysis. Our assertion that a navigator working with patients unat-tached to primary care is patient centred, with a focus on connections and relationships, has some merit.

This scoping review has several limitations. Although a scoping review is iterative and involves revisiting the research question and key terms during searches, our search strategy may have missed studies that reported on interventions not designed to connect people to primary care but where this connection may have been a secondary outcome of the intervention (eg, access to information on cancer screening may have prompted participants to link in with a primary care provider). Additionally, infor-mation in the title and abstracts of such studies may not have referred to primary care. This approach, however, allowed us to undertake a more targeted review. Similarly, while our search strategy sought to include all terms we determined could be synonymous with patient naviga-tion, we may have missed studies where different names were used for the same function.

Studies where there was no indication patients attended a primary care appointment were not included in our review. While this strategy contributed to a more focused search, studies that reported the implementa-tion of programmes but not outcomes are missing. All

Table 3 Examples of patient centredness

Patient-centred care factorDesign phase examples

Implementation phase examples

Analysis phase examples

Total studies*

Patients informed and involved in their care

Two studies: user-friendly and culturally sensitive health materials; bilingual, bicultural community members

17 studies: provided information to patient on difference between emergency and primary care; identified barriers to access and help to overcome barriers

No studies

19

Receptive and responsive health professionals

Three studies: clinics added capacity for walk-in appointments, navigator visited clinics to provide information and establish working relationship

Six studies: after connection, navigator worked with provider to schedule other visits as per care plan; assisted with patient education and follow-up

Two studies: providers wanted to continue in programme; information to providers more complete and accessible than previously 11

Coordinated, supportive healthcare environment

Four studies: collaborative organisation linked emergency department with 18 clinics; each hospital adopted unique provider arrangement and approach

One study: emergency physicians encouraged to establish relationships with clinics

One study: community mobilised around population health issues through increased local media attention

6

*Some studies included more than one instance of the patient-centred factor in more than one phase of the intervention.

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of our included studies originated in the USA, which we acknowledge would impact on generalisability. These limitations highlight the need for consistent documen-tation of processes to improve access to care and the outcomes measured.

We did not look for or report on the effectiveness of the interventions or programmes in our included studies. While we are unable to report on the impact, we consider our approach to looking at descriptions and uses of patient navigation in this specific context of connection to primary care, with a focus on patient-centred care, is consistent with the current focus on patient-reported outcome measures and acknowledging the patient expe-rience of care.

This paper contributes to the discussion of access to primary care by considering patient navigation to connect vulnerable populations to providers in three ways. First, we aligned components of the patient navigation studies reviewed to an existing generic navigation framework. This framework appears to be appropriate for consid-ering navigators facilitating access for people without a primary care provider to regular care. Second, a relational approach acts as the backdrop to connecting vulnerable people to care, based on principles of patient-centred care. Finally, in the absence of a consistent definition of patient navigation in facilitating access to primary care, we have added to an existing description of patient naviga-tion activities, which will assist clinicians and researchers to design and implement similar programmes.

Implications for practiceThe studies included in the review used navigators in a range of settings, from emergency departments, inpa-tient wards, outpatient services and in the community. Most of these studies demonstrate established principles of patient navigation and use a patient-centred approach, particularly when using a navigator (person) rather than a process, such as an electronic system. For providers and organisations wanting to link vulnerable people to primary care in a patient-centred way, navigators may assist in this process.

Future researchAnalysis of cost effectiveness, while not a focus of this review, was nevertheless absent in the cited studies. As the concept of navigator continues to show promise, further research is required to measure impact and give direc-tion to settings interested in using this intervention. For example, the link between patient navigation principles and outcomes of interest require further exploration.

COnClusIOnPatient navigators may be used across healthcare settings to improve access to primary care. Navigators are inher-ently patient-centred due to their relational approach and ability to connect people to primary care. Interventions

to improve access to primary care require further study to determine their impact and cost-effectiveness.

Acknowledgements We wish to acknowledge the peer reviewers of the original version of this paper who provided valued and insightful suggestions to improve the structure, flow and clarity of this paper.

Contributors AP involved in writing protocol, searches, screening, extraction, drafting of results and writing of manuscripts. VL and TB involved in content expert input (methodology) and editing manuscripts. GR oversaw the project, assisted with screening, content expert input, drafting of results and editing of manuscripts.

Funding This work was supported by the Professor Leon Piterman AM PhD scholarship, Southern Academic Primary Care Research Group, Monash university.

Competing interests None declared.

Patient consent Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

data sharing statement Further details on studies included in this scoping review can be retrieved by contacting the corresponding author at annette. peart@ monash. edu.

Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

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